13A-7a ChangeTitleApp2017 06FINALwatermark

CONTRACTORS STATE LICENSE BOARD

9821 Business Park Drive, Sacramento, CA 95827 Mailing Address: P.O. Box 26000, Sacramento, CA 95826 800-321-CSLB (2752) | cslb. |

STATE OF CALIFORNIA Governor Gavin Newsom

FOR CSLB USE ONLY

Application to Report Change of Title for Current Officer or Personnel of Existing Corporate or Limited Liability Company License ? No Fee

Use this application only to change the title of a current officer or member of the personnel already on record for an existing corporate license (officer only) or for an

existing limited liability company (LLC) license (officer, manager, or member).

Use one application for each officer or personnel title change. Each additional officer or personnel must use a separate application.

If you have additional licenses with the same corporate or LLC registration number (as issued by the California Secretary of State and listed in box 3 in Section 1), you must submit a copy of this application for each license. All licenses using the same corporate or LLC registration number must show the same officers, managers, and/or members as their personnel of record.

To add new personnel to an existing corporate or limited liability company license, use form 13A-7 ? Application to Add New Personnel to Existing Corporate or Limited Liability Company License.

To disassociate personnel from an existing license, including a responsible managing officer (RMO), responsible managing manager, responsible managing member, or responsible managing employee (RME), use form 13M-5 ? Disassociation Request.

To replace a current qualifying individual (RMO, responsible managing manager, responsible managing member, or RME) on an existing license, use form 13A-2a ? Application for Replacing the Qualifying Individual.

Please type or print legibly in black or blue ink.

SECTION 1 ? BUSINESS NAME AND ADDRESS

Please provide the full legal business name as it appears on the license. P.O. Boxes and private mail boxes (PMB) are not acceptable for the street

address. Also include the license number as issued by CSLB and the registration number as issued by the California Secretary of State.

1. FULL BUSINESS NAME

2. CSLB LICENSE NUMBER 3. CORPORATE / LLC REGISTRATION #

4. BUSINESS MAILING ADDRESS ? Number/Street or P. O. Box

City

State

ZIP Code

5. BUSINESS STREET ADDRESS ? Number/Street Only ? No P.O. Boxes or PMBs

City

State

ZIP Code

6. BUSINESS PHONE NUMBER

( )

BUSINESS FAX NUMBER

( )

BUSINESS E-MAIL ADDRESS

SECTION 2 ? CORPORATE OR LLC PERSONNEL'S FULL LEGAL NAME AND NEW TITLE

Please provide the full legal name of the member of the personnel. If the individual does not have a middle name, write "None" or "No Middle Name" in the

space provided. If the individual has only an initial for their first or middle name, write "(Initial Only)" after the initial.

7. PERSONNEL'S FULL LEGAL NAME ? Last

First

Middle

DATE OF BIRTH

SOCIAL SECURITY # / ITIN HOME PHONE NUMBER

( )

8. CURRENT PERSONNEL TITLE

NEW TITLE OR POSITION (check only one) May NOT be an RMO or RME (see above about replacing a qualifying individual). Officer title = president, secretary, and/or treasurer

Corporation: Officer - Title(s)

LLC: Officer - Title(s)

Manager Member

STATE TAX AND OTHER OBLIGATIONS NOTICE

The State Board of Equalization and Franchise Tax Board may share taxpayer information with CSLB. You are obligated to pay your state tax obligation. CSLB may suspend or refuse to issue, reactivate, reinstate, or renew a license if your state tax obligation, child support obligation, or any outstanding final liability to CSLB, the Department of Industrial Relations, or the Employment Development Department is not paid. (BPC sections 30, 31, and 7145.5)

9. I certify under penalty of perjury under the laws of the State of California that all statements, answers, and representations made in this application, including all supplementary statements attached hereto, are true and correct, and that I have reviewed the entire contents of this application. In signing and submitting this application, I also authorize the Franchise Tax Board to provide CSLB with required tax information pursuant to Business and Professions Code (BPC) section 7145.5.

Date

Signature of Corporate or LLC Personnel

Printed Name of Corporate or LLC Personnel

Collection of Social Security Numbers and Individual Taxpayer Identification Numbers

All information requested on the application is mandatory, including disclosure of U.S. Social Security numbers (SSN) and individual taxpayer identification numbers (ITIN). Collection of the SSN and ITIN is authorized by BPC sections 30, 31, and 7145.5. SSNs and ITINs are used exclusively for the purpose of tax enforcement, compliance with any judgment or order for family support in accordance with Family Code section 17520, measurement of employment outcomes of students who participate in career technical education programs offered by the California Community Colleges as required by BPC section 30, and investigation of tax evasion and violations of cash-pay reporting laws as set forth in Section 329 of the Unemployment Insurance Code. If you fail to disclose your SSN or ITIN, your application will not be processed and you will be reported to the Franchise Tax Board; they may assess a $100 penalty against you.

Collection of Personal Information

CSLB collects the personal information requested on this form as authorized by BPC sections 30, 31, 141, 480, 7066, 7083, and 7145.5 and Title 16 of the California Code of Regulations section 816. CSLB uses this information to identify and evaluate applicants for licensure, issue and renew licenses, and enforce licensing standards set by law and regulation. Submission of the requested information is mandatory. CSLB cannot consider this application unless you provide all of the requested information. You may review the records maintained by CSLB that contain your personal information, unless the records are identified as confidential information and exempted from disclosure by the Information Practices Act, including Civil Code section 1798.40. CSLB makes every effort to protect the personal information you provide us; however, it may be disclosed in response to a Public Records Act request as allowed by the Information Practices Act; to another government agency as required by state or federal law or as provided in Civil Code section 1798.24; or in response to a court or administrative order, a subpoena, or a search warrant. The Custodian of Records is responsible for maintaining the information on this form and may be contacted at the address and telephone number listed in the letterhead at the top of this application for questions about this notice or access to records.

*chng-per-title*

Application ? Page 1 of 1

13A-7a (rev. 06/17)

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